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This colorized transmission electron micrograph
(TEM) revealed some of the ultrastructural morphology displayed
by an Ebola virus virion. Photo courtesy of CDC/Cynthia
Goldsmith. Because of their contact with
patients or infective material from patients, environmental
services and facility visitors, healthcare workers and healthcare
organizations utilize multiple interventions to prevent and/or
manage infections in healthcare workers.
Initially, new employees are
generally required to have a pre-employment physical; presumably
any infection can be identified at that time and treatment
initiated or management strategies employed prior to contact
with patients or coworkers. Because healthcare workers are
at risk for exposure to and possible transmission of vaccine-preventable
diseases, maintenance of immunity is an essential part of
prevention and infection control programs for healthcare workers.
Optimal use of immunizing agents safeguards the health of
workers and protects patients from becoming infected through
exposure to infected workers.
On the basis of documented
transmission, healthcare workers are considered to be at significant
risk for acquiring or transmitting (CDC, 1997):
- Hepatitis B,
- Influenza,
- Measles,
- Mumps,
- Rubella, and
- Varicella.
All of these diseases are vaccine-preventable. The Advisory
Committee on Immunization Practices (ACIP) has developed the
following adult immunization schedule for October 2007 - November
2008 (ACIP, 2007).
View
the Adult Immunization Schedule.
In addition to pre-employment screening or testing for infection
and illness, vaccinations for vaccine-preventable illnesses,
maintenance of good health, and the utilization of engineering
and work practice controls are all methods to minimize the
risk of acquiring or transmitting an infectious disease.
The estimated number of occupational HBV infections among
U.S. healthcare workers has decreased significantly over the
last 20 years. Data from surveillance systems indicated a
96% decline in HBV infections among healthcare workers over
a 17-year period-from nearly 11,000 cases in 1983 to fewer
than 400 in 1999. This reduction is largely due to the adoption
of universal precautions in the mid-1980s by healthcare facilities
and the 1992 OSHA Bloodborne Pathogen Standard (29 CFR 1910.1030),
which required employers to offer HBV vaccinations to exposed
workers (NIOSH, 2004).
During the time frame from 1981 through December 2002, 57
cases of documented occupational transmission of HIV to healthcare
workers occurred. In that same time frame, 139 cases of occupational
transmission of HIV to healthcare workers were possible (NIOSH,
2004).
Most documented cases of occupational HIV transmission occurred
among nurses (24 cases or 42.1%) and laboratory workers (19
cases or 33.3%). These cases were reported to the HIV/AIDS
Reporting System. Among the documented cases of HIV following
occupational exposure, 84% resulted from percutaneous exposure
(NIOSH, 2004).
Healthcare workers must be educated concerning the risk of
and prevention for bloodborne pathogens, including the need
to be vaccinated against HBV. Employers are required to establish
exposure control plans that include post-exposure follow-up
for employees and to comply with the incident reporting requirements
of the 1992 OSHA Bloodborne Pathogens Standard.
Exposure prevention remains the primary strategy for reducing
occupational bloodborne pathogen infections. However, occupational
exposures will continue to occur, and post exposure prophylaxis
(PEP) is an important element of exposure management (CDC,
2005).
Access to clinicians who can provide post-exposure care should
be available during all working hours, including nights and
weekends. Hepatitis B immunoglobulin (HBIG), HBV vaccine and
antiretroviral agents for post-exposure prophylaxis (PEP)
should be available in a timely manner, either by providing
access onsite or by developing linkages with providers or
facilities that can provide such service off-site. Those individuals
who are responsible to provide post-exposure management must
be knowledgeable about the evaluation and treatment protocols
and the facility's plans for accessing post-exposure medications
(CDC, 2005).
The recommendations provided by the CDC (See Tables 3 and
4) apply to situations in which healthcare providers have
been exposed to a source person who either has or is considered
likely to have HIV infection. These recommendations are based
on the risk for HIV infection after different types of exposure
and on limited data regarding efficacy and toxicity of PEP.
If PEP is offered and taken and the source is later determined
to be HIV-negative, PEP should be discontinued (CDC, 2005).
Although concerns have been expressed regarding HIV-negative
sources being in the window period for seroconversion, no
case of transmission involving an exposure source during the
window period has been reported in the United States. Rapid
HIV testing of source patients can facilitate making timely
decisions regarding use of HIV PEP after occupational exposures
to sources of unknown HIV status. Because the majority of
occupational HIV exposures do not result in transmission of
HIV, potential toxicity must be considered when prescribing
PEP. Because of the complexity of selecting HIV PEP regimens,
when possible, these recommendations should be implemented
in consultation with persons having expertise in antiretroviral
therapy and HIV transmission. Reevaluation of exposed healthcare
providers should be strongly encouraged within 72 hours postexposure,
especially as additional information about the exposure or
source person becomes available (CDC, 2005).
Healthcare workers must be informed to report occupational
exposures immediately after they occur because prophylactic
treatment is most effective when administered as soon after
the exposure as possible. PEP is preferably within hours rather
than days of exposure (CDC, 2005).
Healthcare facilities will have policies and procedures for
the prevention of occupational exposure in place as part of
their administrative controls related to infection control,
however, these facilities will also have policies and procedures
in place regarding reporting, evaluation, counseling, treatment
and follow-up of occupational exposure (CDC, 2005).
In the event that wounds or skin sites have been in contact
with blood or body fluids, the sites must immediately be washed
with soap and water; mucous membranes should be flushed with
water. No evidence exists that using antiseptics for wound
care or expressing fluid by squeezing the wound further reduces
the risk of transmission; however, the use of antiseptics
is not contraindicated (CDC, 2005).
In the event of an occupational exposure, the exposure and
post-exposure management should be recorded in the exposed
person's medical record. A facility may have a specific form
for such an exposure. Employers must follow all federal and
state requirements for recording and reporting occupational
injuries and exposures (CDC, 2005).
The CDC (2005) recommends that the following information
be recorded in the exposed person's confidential medical record:
- Date and time of exposure;
- Details of the procedure being performed, including where
and how the exposure occurred; if related to a sharp device,
the type and brand of device, and how and when in the course
of handling the device the exposure occurred;
- Details of the exposure, including type and amount of
fluid or material and the severity of the exposure (e.g.,
for a percutaneous exposure, depth of injury and whether
fluid was injected; for a skin or mucous membrane exposure,
the estimated volume of material) and the condition of the
skin (e.g., chapped abraded, intact).
- Details about the exposure source (e.g., whether the
source material contained HBV, HCV or HIV; if the source
is HIV-infected, the stage of disease, history of antiretroviral
therapy, viral load, antiretroviral resistance information,
if known).
- Details about the exposed person (e.g., HBV vaccination
and vaccine response status).
- Details about counseling, post-exposure management and
follow-up.
Basic and Expanded HIV Postexposure Prophylaxis Regimens
can be found in the Appendix of Updated US Public Health
Service Guidelines for the Management of Occupational Exposures
to HIV and Recommendations for Post Exposure Prophylaxis
(2005) available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm
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Table 3.
Recommended HIV postexposure prophylaxis (PEP) for percutaneous
injuries
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Infection
Status of Source
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Exposure
Type
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HIV-Positive,
class 1*
|
HIV-positive,
class 2*
|
Source of
unknown HIV
status†
|
Unknown source§
|
HIV-negative
|
| Less severe¶ |
Recommend basic 2-drug PEP |
Recommend expanded >/= 3-drug PEP |
Generally, no PEP warranted; however, consider basic
2-drug PEP** for source with HIV risk factors†† |
Generally, no PEP warranted; however, consider basic
2-drug PEP** in settings in which exposure to HIV-infected
persons is likely |
No PEP warranted |
| More severe§§ |
Recommend expanded 3-drug PEP |
Recommend expanded >/= 3-drug PEP |
Generally, no PEP warranted; however, consider basic
2-drug PEP** for source with HIV risk factors†† |
Generally, no PEP warranted; however, consider basic
2-drug PEP** in settings in which exposure to HIV-infected
persons is likely |
No PEP warranted |
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* HIV-positive, class 1 _ asymptomatic
HIV infection or known low viral load (e.g., <1,500
ribonucleic acid copies/mL). HIV-positive, class 2 -
symptomatic HIV infection, acquired immunodeficiency
syndrome, acute seroconversion, or known high viral
load. If drug resistance is a concern, obtain expert
consultation. Initiation of PEP should not be delayed
pending expert consultation, and, because expert consultations
alone cannot substitute for face-to-face counseling,
resources should be available to provide immediate evaluation
and follow-up care for all exposures.
† For example, deceased source person with no
samples available for HIV testing.
§
For example, a needle from a sharps disposal container.
¶ For example, solid needle or superficial injury.
** The recommendation "consider PEP" indicates
that PEP is optional; a decision to initiate PEP should
be based on discussion between the exposed person and
the treating clinician regarding the risks versus benefits
of PEP.
†† If PEP is offered and administered and
the source is later determined to be HIV-negative, PEP
should be discontinued.
§§
For example, large-bore hollow needle, deep puncture,
visible blood on device or needle used in patient's
artery or vein.
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Table 4.
Recommended HIV postexposure prophylaxis (PEP) for mucous
membrane exposures and nonintact skin* exposures
|
|
Infection
status of source
|
|
Exposure
type
|
HIV-positive,
class 1†
|
HIV-positive
class 2†
|
Source of
unknown HIV
status§
|
Unknown
source¶
|
HIV-negative
|
| Small volume** |
Consider basic 2- drug PEP†† |
Recommend
2-drug PEP
|
Generally, no PEP warranted§§ |
Generally, no PEP warranted |
No PEP warranted |
| Large Volume¶¶ |
Recommend basic 2-drug PEP |
Recommend expanded >/= 3-drug PEP |
Generally, no PEP warranted; however, consider basic
2-drug PEP††
for source with HIV risk factors§§ |
Generally, no PEP warranted; consider basic 2-drug PEP††
in settings in which exposure to HIV-infected persons
is likely |
No PEP warranted |
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* For skin exposures,
follow-up is indicated only if evidence exists of compromised
skin integrity (i.e., dermatitis, abrasion, or open
wound).
† HIV-positive, class 1 - asymptomatic HIV infection
or known low viral load (e.g., <1,500 ribonucleic
acid copies/ml). HIV-positive, class 2 - symptomatic
HIV infection, AIDS, acute seroconversion, or known
high viral load. If drug resistance is a concern, obtain
expert consultation. Initiation of PEP should not be
delayed pending expert consultation, and, because expert
consultation along cannot substitute for face-to-face
counseling, resources should be available to provide
immediate evaluation and follow-up care for all exposures.
§ For example, deceased source person with
no samples available for HIV testing.
¶ For example, splash from inappropriately disposed
blood.
**For example, a few drops.
§§ If PEP is offered and administered
and the source is later determined to be HIV-negative,
PEP should be discontinued.
¶¶ For example, a major blood splash.
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